Leave Behind Narcan Form ONLY NEEDED WHEN NO EMEDS REPORT EXISTS
Please fill out the info below for the person receiving the Leave-Behind Kit
Incident Number (if applicable)
Station or Unit Number
*
Age
*
Gender
*
Male
Female
Unknown
Race
*
White
Hispanic or Latino
Black or African American
Native American or American Indian
Asian / Pacific Islander
Other
Incident Location (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Individual's Address (if different than incident location)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Individuals's Phone Number (if they want to be contacted for follow-up)
-
Area Code
Phone Number
Number of doses dispensed
*
2 (one bag)
4 (two bags)
6 (three bags)
8 (four bags)
10 (five bags)
There are two doses per bag
Kit ID Number
*
A22
B22
C22
D22
E22
F22
G23
H23
I23
J23
K23
L24
Found on front of red bag
Reason for naloxone
*
Self Use
Family Member
Friend
Preparedness
Preferred not to answer
Clinican Name
*
In case we need to reach you
Notes (No PHI Please)
Submit
Should be Empty: